 Well, I have always been very self-conscious of the appearance of my mouth, and have been bothered by it since about the age of 11 or 12, but was really unaware of what could be done, or if any, until I had to go for other dental care at Fort Belvoir Hospital, and then therefore was referred to Walter Reed. In evaluating a patient for orthodontic surgery at Walter Reed Hospital, we find that a rigid checklist of consultations and accomplishments must be done prior to discussing the patient's problem and evolving a treatment plan. To bring you up to date, previously, sephalometric x-rays, panorax x-rays, and appropriate periapical x-rays were taken. Study models were obtained upon which model operations were done in order to establish the procedure that would best solve the patient's problem. The sephalometric analysis that is drawn from the sephalometric x-ray is thoroughly studied, and the deficiency is then determined. With all this information, a recommendation for surgical correction can then be made to the patient. The procedure we have selected to correct your malocclusion, Mrs. Rose, was developed in the early 1930s in Europe. This particular procedure would entail an incision inside your mouth, won't allow for any scar on the skin, and then a separation of the entire upper jaw from the rest of the skull and a freeing up of all of the teeth with their bone so that they can be placed in the new position in proper alignment with the lower jaw teeth. In these pre-operative views of the patient with their teeth in normal occlusion, a flattening of the middle one-third of her face is evident. There also is a pseudo-prognathic appearance to the mandible. In the profile view of the occlusion, the prognathic relationship of the mandibular teeth to the maxillary teeth can be seen. As the patient bites in centric jaw relation, there is improvement in her facial appearance. The mandible no longer appears so prognathic. There is also an improvement in the position of the anterior teeth of the maxillop to those of the mandible. Occlusal interference by the anterior teeth, however, will not permit posterior closure. A surgical repositioning of the retreated maxillop will correct the occlusion and allow for proper positioning of the maxillop to the mandible. Iliac donor bone required for the graft to the maxillop is taken at a preliminary operation. At surgery, the hip incision is planned transversely to make it invisible under a bikini-type bathing suit. The incision goes through full thickness skin, which is retracted. The crest of the ilium is exposed by dissecting through the overlying external and internal oblique abdominal muscles. Following reflection of the medial periosteum and overlying iliac muscle, the size of the graft is measured and marked with an osteotome. The inner table is selected because it results in the smallest amount of morbidity to the patient. Half the width of the crest is removed along with the inner table and its cancerous bone. The specimen is placed in a receptacle and covered with a saline-saturated sponge. The incision is then closed in layers. Lidocaine 2% with 1 to 100,000 epinephrine is infiltrated for hemostasis, along with a 1 to 5,000 neosinephrine solution. The osteotomy incision is made from the malar buttress to the midline through the mucosa to bone. The lateral wall of the maxilla and antrowalls are exposed by mucoperiosteal reflection. The nasal mucoperiosteum is also reflected. The osteotomy site is then marked on the lateral wall of the maxilla with methylene blue. Osteotomy is accomplished under a constant stream of saline irrigation using the striker rotary handpiece and a fissure burr. The bone incision is extended from the posterior wall of the maxilla to the piriform aperture of the nose. The same procedure is then repeated on the right side, where a mucoperiosteoflap is elevated, exposing the lateral wall of the maxilla. The line of the osteotomy is again marked with methylene blue, and osteotomy is performed with the burr. Retraction of the posterior maxillary wall tissues is readily afforded by a lane retractor resting against the pteragoid plate. The tissues over the nasal spine and the nasal mucosa are reflected. An angled osteotome is inserted to separate the vomer from the maxilla. The assistant surgeon places his finger at the posterior covena to inform the surgeon when this dissection is complete. The lateral nasal wall is then severed by mallet and osteotome. Final detachment of the maxilla can be accomplished by fracturing the pteragoid plates using a special rounded chisel, which fits high in the third molar region of the maxilla. Once the pteragoid plates have been separated, the maxilla moves freely. It can be further disimpacted by the use of the tessier disimpaction instruments demonstrated here. An additional method used to free the maxilla is by downward and forward traction manually on the maxillary incisor teeth. Freeing the maxilla, which is now pedigaled upon the soft palate and pterago-palatine tissues, once freed from its attachment to the cranium, the maxilla moves freely to a more anterior and desirable position. Burr holes are placed in the lateral walls of the maxilla, where interosseous wires are loosely placed. Care must be exercised in tightening these wires to prevent them from pulling through the very thin bone. In areas where the amount of separation between the fragments does not lend itself to placement of wires through a direct approach, an indirect approach can be accomplished using a passing wire. After all wires have been placed, advancement and fixation of the maxilla in its new desired position is accomplished with the aid of an occlusal splint. The bone, which was taken from the hip, is now prepared. You will note that the surgeon is cutting the bone at an angle, so as to create a wedge between the maxillary fragments. Based on the model operation advancement dimension, the pteragoid plate bone graft is measured and prepared. This will be inserted between the pteragoid plate and the posterior wall of the maxilla to prevent relapse of the maxilla posteriorly, following removal of the intermaxillary fixation. The posterior and lateral maxillary walls are grafted under direct vision from a fiber optic light source. The wedge-shaped fragment fills the space created by the osteotomy in such a manner that when the wires are tightened, they will fit snugly against the graft. On the left side, cancelous bone is placed over the osteotomy cut, rather than in between it, as there is a close approximation of the fragments. Additional bone can also be placed in order to fill out an area of flattening in the middle face, or in the lateral nasal region. Fixation now is positive. The incisions are closed with a 3-0 running dexon horizontal mattress suture. In order to achieve further stability, a circumzygomatic wire is passed over each zygomatic arch. The technique utilized on the right side is that of the curved autopsy needle and modified spinal anesthesia needle to place the wire over the zygomatic arch at the appropriate level. The wire is seated by a seesaw motion. It is twisted around the end of the needle holder, and a suspension wire is then placed through it to the mandibular arch bar. On the left side, a special passing awl is used to accomplish the circumzygomatic wire placement. The awl penetrates the skin and has moved downward under the arch until it enters the mouth. The wire is threaded through the awl, and it is withdrawn to the region of the zygomatic arch, then passed laterally over it and inferiorly back into the oral cavity. Here again, the wire will be seated on the zygomatic arch by a seesaw motion. On this side, the wire is tightened over a hemostat, and the suspension wire is again placed through it to the mandibular arch bar. This system of suspension permits the cutting of the distal suspension wires without losing the original wires around the zygomatic arches. The desired occlusion is verified, and final fixation tightening is accomplished at the completion of surgery. Eight weeks post-surgery, the patient has needed fullness in the middle face region. The flatness of the nasal region has been relieved. The occlusion now is no longer pseudo-prognathic, but is normal for the patient. In the post-surgical comparison of the right and left profiles, one notes the improvement in the prognathic appearance, although there remains some fullness of the lower lip. In a close-up of the occlusion, it can be noted that a Class I maxillary mandibular relationship has been achieved, and that there has been excellent healing in the incision over the osteotomy site. In this case, the maxilla was advanced 10 millimeters. The patient is pleased with her post-operative results. Ortho-nathic surgery in the maxilla has resolved this malocclusion problem. It's hard for me to explain how I feel about the results of the surgery. All I can say is that I am very happy with it, and it's made quite a difference. Most of my friends tell me they can tell quite a difference in personality, and my husband says the same thing. My main reason for having the surgery was, of course, my appearance, because I was always very self-conscious of it. But the one thing I didn't even think about during the whole process was the fact that now I could bite and chew my food better. My teeth actually hit together. It's hard to explain how you feel about something that you've wanted all your life.